Turf wars

Are nurse practitioners and physician assistants just as good as doctors? Should they have more latitude to prescribe drugs, issue orders and care for patients?

There’s a turf battle being waged over the role of mid-level health care professionals. On one side are proponents for expanding the scope of practice for mid-levels and using their capabilities as fully as possible. On the other side are those who fear this may be assigning too much responsibility to professionals whose training is not equivalent to that of a physician.

So who’s right?

It all depends, I guess, on your perspective. In underserved areas, nurse practitioners, midwives, advanced-practice nurses and physician assistants have been a boon. They have helped increase access to basic health services. They’re valuable team players, augmenting physicians in overall care of the patient. These clinicians can assess, diagnose, treat, prescribe, manage chronic conditions and even do some procedures.

There’s little to suggest the mid-level professionals are any less proficient than physicians at providing quality care, and they do so typically at a lower cost. Their patient satisfaction scores also are generally high.

Various studies have borne out all of this. For instance, this study, which appeared some years ago in the Journal of the American Medical Association, tracked patients at four community clinics and one primary clinic at an academic medical center, and found patient outcomes and satisfaction were the same whether patients saw a physician or a nurse practitioner. This study found that low-income, medically underserved patients who needed chronic care for cardiovascular disease perceived their care was better when it was directed by nurse practitioners and community health educators.

Few could argue that mid-level clinicians shouldn’t be part of the model of care.

And yet: Their training isn’t as extensive as that of a physician. Their skills and knowledge base don’t necessarily equip them to care for patients with complex needs. While they can and do play a vital role on the team, they are not the equivalent of someone who is trained and licensed as a doctor.

Unfortunately it’s all too easy for the facts to be either overlooked or overblown in the discussion about the best and most appropriate use of mid-level clinicians. Is some of it about turf protection? I’m sure this figures into it to some degree. Not all physicians like the idea of sharing their power or being seen as interchangeable with someone who doesn’t have the initials M.D. or D.O. behind their name. Given that many mid-level providers, especially nurse practitioners and advanced-practice nurses, are women, I wouldn’t be surprised if there’s some element of sexism involved as well.

Mid-level clinicians, for their part, can feel insulted and devalued when they perceive their skills are being dismissed as not good enough for medical school. They’re often touchy about their titles; in fact the American Academy of Nurse Practitioners officially opposes the term "mid-level" as being inappropriate and potentially derogatory.

At its worst, the conversation devolves into snarkitude and name-calling, such as this online discussion awhile back at Kevin, MD, in which one of the commenters, apparently a physician, sniped: "NP degrees exist in part because the NPs were too LAZY to go back and do a post bacc to obtain the necessary prerequisites to get into medical school or even PA school."

Look beyond the arguing and the turf warfare, however, and you’ll see there are legitimate issues at stake.

There has been a considerable national push to train and deploy more mid-level health care professionals. Many policymakers see the mid-levels as an important part of the solution to increasing access to health care services and lowering the cost. At least 28 states – including Minnesota – are considering legislation to expand the scope of practice for nurse practitioners, a move that would allow them, in some states, to have more prescribing privileges and, in other states, to practice without supervision.

Some of this is in response to the very real shortage of primary care doctors. The Associated Press explored some of these issues in a recent story:

One patient, Karen Reid of Balrico, Fla., said she was left in pain over a holiday weekend because her nurse practitioner couldn’t prescribe a powerful enough medication and the doctor couldn’t be found. Dying hospice patients have been denied morphine in their final hours because a doctor couldn’t be reached in the middle of the night, nurses told The Associated Press.

Massachusetts, the model for the federal health care overhaul, passed its law in 2006 expanding health insurance to nearly all residents and creating long waits for primary care. In 2008, the state passed a law requiring health plans to recognize and reimburse nurse practitioners as primary care providers.

That means insurers now list nurse practitioners along with doctors as primary care choices, said Mary Ann Hart, a nurse and public policy expert at Regis College in Weston, Mass. "That greatly opens up the supply of primary care providers," Hart said.

There’s another side to this, however. Are patients invariably better served by mid-level health professionals? Or are there times when it’s best for patients to have their care overseen by a doctor? Proponents for the more widespread use of mid-levels often imply in their arguments that physicians and mid-levels are more or less interchangeable – "the same as" – even though there are very clear differences in the amount and type of training they receive.

It’s not unreasonable to question where this road might be taking us. Dr. Timothy Malia, a family doctor and blogger in upstate New York, worried and reflected recently about a patient of his who went for a cardiac follow-up visit and was seen not by a cardiologist but by a nurse practitioner:

… To see the "NP" after the name of the provider who saw my patient, and not an "MD," really hit my soul as I sat in that quiet office late at night. "Why?" I ask. Why would a patient with multiple heart problems and cardiac disease risk factors not be seen by one of the cardiology office’s physicians?

Understand that I have many patients who are seen by nurse practitioners and physician assistants in specialists’ offices. They most often seem to be used for work with a narrower focus or for particular procedures. And I have been satisfied with that.

But my patient is complex and had a significant change in his general condition over the last year. He was being seen for an annual follow-up. In that case I want the provider seeing the patient to have my level of formal medical education PLUS advanced study in the particular field. Is it too much to ask that I should be confident that the patient got more advanced care and complex thinking at the specialist’s office than I believe I can offer?

… Honestly, I believe that particular nurse practitioner knows a good deal of cardiology. I do not doubt that. And she may have given a reasonable assessment. But, deep down inside, I cannot be sure that some subtlety of symptoms or exam findings was not integrated into the evaluation.

Dr. Malia wonders if he’s being grumpy and persnickety. I don’t think he is. Although the growth of the mid-level professions has been welcome in many ways, I’m not sure there’s a consensus on the best possible use for these clinicians or where they should fit into the system.

What should the goal be? Is it simply to push patient care down to the lowest and cheapest level? Or is it to provide appropriate care at the appropriate level for the individual patient? Should we be responding to the doctor shortage by promoting the use of mid-level professionals, or should we focus instead on how to shore up the entire medical education and health care system, particularly in primary care?

Ideally, mid-level clinicians should be able to use their skills and training to the fullest capacity. They belong on the team and need to be included. But if we’re going to acknowledge that the mid-levels have something unique and vital to contribute, we also have to acknowledge that physicians bring their own special skills and training to the table. We need to recognize that we can’t substitute one for the other. In the long run, I think we’ll all be far better served when each profession’s role is clearly defined, clearly understood and, yes, respected.

Photo: Wikimedia Commons

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